Health inspection·December 29, 2022

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices 42 CFR §483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2)Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72311 Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 10/19/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1’s quality of care. The facility failed to ensure Resident 1, who was identified as a high risk for falls and had prior history of a fall, received care and services to prevent recurrent falls and injuries in accordance with the comprehensive plan of care and the facility’s policies and procedures (P&P). The facility failed to: 1.-Implement the Risk for Fall / Injury care plan and provide Resident 1 with a landing mat. 2.- Implement the Activities of Daily Living care plan to monitor and anticipate Resident 1’s needs and maintain a safe environment. 3.-Implement the facility’s P&P titled, “Fall Risk / Prevention,” to implement a plan of care to prevent falls. As a result, on 10/3/2022, Resident 1 fell from her bed, landing on the floor, breaking her pelvis bone and sacrum (base of vertebrae connected to the pelvis). Resident 1 was transferred to a general acute care hospital (GACH) and diagnosed with a minimally displaced superior pelvic fracture (broken bone that shifted at the top), a nondisplaced inferior pelvic fracture (broken bone on the bottom) and a sacral fracture; broken in three different areas on the left side, with significant pain. A review of Resident 1’s Face sheet (admission record), indicated Resident 1 was a 95 year-old female, admitted to the facility on 7/30/2022 with diagnoses including difficulty walking and muscle weakness. A review of the Risk for Fall/injury care plan initiated 7/30/2022, indicated Resident 1 was a high risk for falls and injury related to an unsteady gait, cognitive impairment (unable to make decisions), weakness, had a need for assistance with walking and had a history of fall. The care plan interventions included having a front wheel walker during rehabilitation therapy and for the bed to be in the lowest position with a landing mat. A review of Resident 1’s History and Physical (H&P), dated 8/1/2022, indicated Resident 1 had a history of weakness and fall without head strike, with right sided hip strike, and the resident was at the facility for rehabilitation. A review of the Minimum Data Set (MDS – a comprehensive, standardized assessment and care screening tool), dated 8/5/2022, indicated Resident 1 had impaired vision, cognition was moderately impaired (decisions poor; cues/supervision required), and required extensive assistance with one-person physical assist with bed mobility, transferring, walking in room, walking in corridor, dressing, toileting, and personal hygiene. According to a review of the Admission Interdisciplinary Team note (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) dated 8/5/2022, before Resident 1’s admission to the facility, the resident previously had a fall in the kitchen at home. A review of Resident 1’s Fall Risk Assessment, dated 8/8/2022, indicated Resident 1 scored an 18, and a score of ten or greater indicated the resident was a high risk for falls. The fall risk assessment indicated Resident 1 had a fall in the past three months, was chair bound, had poor vision, and required assistive devices (i.e., canes, wheelchairs, walkers, furniture). A review of the Activities of Daily Living care plan initiated 8/8/2022, indicated Resident 1 required the use of a wheelchair or front wheeled walker for ambulation (walking) and had a balance problem when moving from a seated to a standing position, walking, turning around, and moving on and off the toilet. The care plan goal indicated Resident 1 would have no incident of falls, or skin breakdown for 90 days. The care plan interventions indicated to monitor and anticipate the resident’s needs, provide assistance with personal hygiene and toilet needs, and maintain a safe and clutter free environment. A review of Resident 1’s potential for spontaneous fractures care plan initiated 8/8/2022 indicated the resident was at risk for fractures due to a history of fractures and the aging process. The care plan interventions indicated to handle Resident 1 gently on transfer. According to a review of the Physician’s Order Report dated 10/1 – 10/31/2022, on 7/30/2022, the physician ordered for Resident 1’s bed to be in the lowest position with a landing mat, and to minimize potential injury from spontaneous and involuntary movement from bed to landing mat. A review of the Situation, Background, Assessment, Recommendation form (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 10/3/2022, indicated Resident 1 fell from the bed to the floor and sustained a 4 centimeters (cm) by (x) 4 cm laceration on the arm. A review of Resident 1’s nursing progress notes, dated 10/3/2022, indicated Resident 1 was found on the floor at 6:50 AM by a restorative nurse assistant. The nursing progress notes indicated Resident 1 was noted to have a skin tear on her left forearm that measured 4 x 4 cm, and the resident complained of severe pain to her left hip and left leg. A review of Resident 1’s Status Post Fall Assessment dated 10/3/2022, indicated the rehab professional was unable to assess the resident due to the amount of pain the resident was in and it took five people to transfer Resident 1 back to bed. A review of the Medication Administration Record (MAR) dated 10/3/2022, indicated Resident 1 was administered Tylenol 650 milligrams (mg) by mouth at 7 AM for a pain level rated at eight out of ten (using the scale of zero to ten, ten being the most severe pain). The MAR indicated pain rated at an eight indicated intense pain, physical activity was severely limited, and conversing required great effort. A review of the Physician’s Order dated 10/3/2022 at 7:15 AM, indicated Resident 1 was to receive steri-strips (strips of tape put across an incision or minor cut) one time now applied to the forearm skin tear and to monitor for any changes for 14 days. The physician’s order indicated to transfer Resident 1 to a GACH for further evaluation. According to a review of the GACH emergency department (ED) note dated 10/3/2022, Resident 1 was brought in by ambulance for an unwitnessed fall. Resident 1 stated she fell to the floor on her left side and was complaining of “pain all over but especially the left side.” A review of the GACH Imaging (X-ray) results dated 10/3/20222 indicated Resident 1 had a minimally displaced superior pelvic fracture (broken bone that shifted at the top), a nondisplaced inferior pelvic fracture (broken bone on the bottom) and a sacral fracture; broken in three different areas on the left side. A review of the facility’s fracture care plan initiated 10/3/2022 (after the fall) indicated Resident 1 sustained sacral and pelvic fractures. A review of the GACH Physical Therapy (PT) Initial Evaluation dated 10/5/2022 indicated Resident 1 had three documented falls in the past noted in her chart and the PT diagnoses included a decline in function, a decline in functional tolerance, and Resident 1 had left hip pain when moved or touched. A review of the GACH discharge summary dated 10/8/2022 indicated Resident 1 was found to have a left pelvic fracture that was treated without surgery and a urinary tract infection. The resident was treated with Zosyn (antibiotic) and Vancomycin (antibiotic) and had significant pain with movement. During an observation on 10/19/2022 at 2:13 PM, Resident 1 was in bed sleeping. The landing mat was observed on both sides of the bed with bed in a low position. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 10/19/2022 at 2:32 PM, Resident 1’s rehabilitation notes were reviewed. The DOR stated the resident will have PT and occupational therapy (OT) five times a week, required maximum assist with bed mobility, and was total assist with transfer sit to standing. The DOR stated Resident 1 was not able to ambulate during the evaluation. On 10/19/2022 at 3:19 PM, during an interview, Resident 1 stated she fell, and it took two people to get her back to bed. Resident 1 stated, “I cannot walk. I am in the bed. I cannot walk. They try to force me [to do therapy], but it is very hard to do it. It’s amazing what could happen in one second and your life can change. I could walk before.” During an interview with Licensed Vocational Nurse (LVN) 1 on 10/20/2022 at 4:14 AM, LVN 1 stated, Restorative Nurse Assistant (RNA) 1 called her around 6:50 AM in the morning and stated Resident 1 was laying on the floor next to her bed. LVN 1 stated when she entered the room, Resident 1 was on the floor holding the bed control. When asked whether Resident 1 had a landing mat, LVN 1 stated, “She did not have a mat. We did not have any history of falling at that time.” On 10/20/2022 at 4:30 AM, during an interview regarding Resident 1’s fall on 10/3/2022, RNA 1 stated, “I was passing the trays and I saw the resident lying on the floor and I called the charge nurse. She was lying on her back. She did not have a landing mat on the floor.” RNA 1 stated Resident 1 “was not considered a fall risk at that time because she always called for assistance.” During an interview on 11/8/2022 at 11:50 AM, the Assistant Director of Nursing (ADON) stated, “The resident was a fall risk and required extensive assistance with her Activities of Daily Living. During her admission she was a fall risk.” When asked was it important for Resident 1 to have a landing mat, the ADON stated, “Yes. The landing mat is to minimize injury.” The ADON further stated Resident 1 had diagnoses of osteopenia (a loss of bone mineral density that weakens bones) and because the resident was high risk for fracture due to the osteopenia, the landing mat can minimize the potential for injury. During an interview on 11/10/2022 at 2 PM, Nurse Practitioner (NP) 1 stated she was not aware the facility had not provided Resident 1 with a landing mat. NP 1 stated, “I know that she has had falls in the past and with [the most recent fall, 10/3/2022] she had a significant fracture.” NP 1 stated that she “typically orders the landing mat for patients with a history of repeated falls and to minimize the potential for injury.” A review of the facility’s (P&P) titled, “Fall Risk/Prevention,” revised 7/2017, indicated it was the policy of the facility to identify residents that were at a risk for falls and to implement a plan of care to prevent falls. The P&P indicated that for a fall risk assessment score of ten or above, the resident was at risk for falls and a plan of care would be developed with approaches in an attempt to prevent falls. A review of the facility’s P&P titled, “Falling Star Program,” revised 7/2018, indicated its purpose was to identify residents who were a high risk for falls, and the general safety precautions and interventions should be used for residents which may include maintaining the bed in the lowest position and providing floor mats at the bedside. A review of the facility’s P&P titled, “Falls by a Resident,” revised 7/2017, indicated if the fall risk assessment score was ten or above, the resident was at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls. The facility failed to ensure Resident 1, who was identified as a high risk for falls and with a prior history of a fall, received care and services to prevent falls and injuries in accordance with the comprehensive plan of care and the facility’s P&P. The facility failed to: 1.-Implement the Risk for Fall / Injury care plan and provide Resident 1 with a landing mat. 2.- Implement the Activities of Daily Living care plan to monitor and anticipate Resident 1’s needs and maintain a safe environment. 3.-Implement the facility’s P&P titled, “Fall Risk / Prevention,” to implement a plan of care to prevent falls. As a result, on 10/3/2022, Resident 1 fell from her bed, landing on the floor, breaking her pelvis bone and sacrum. Resident 1 was transferred to a GACH and diagnosed with a minimally displaced superior pelvic fracture, a nondisplaced inferior pelvic fracture and a sacral fracture; broken in three different areas on the left side, with significant pain. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.